Evidence of sustainability of a quality improvement approach in Malawi

From 2002-2010, CARE Malawi implemented Supporting and Mitigating the Impact of HIV/AIDS for Livelihoods (SMIHLE) project. SMHILE's midterm evaluation highlighted implementation issues, which a quality improvement approach, the Community Score Card (CSC), was introduced to address. The CSC methodology involves citizen representatives and service providers in a mutual process of identifying problems, generating solutions, and working in partnership to improve services. Despite the fact that CARE's support for the SMHILE project ended in 2010, community members have continued to implement the CSC on their own. In 2012, over 2 years after the end of SMHILE, four focus group discussions with women, the CSC committee, and the broader community were conducted to examine factors that contributed to the CSC sustainability, how the community has applied the CSC, and the outcomes that have resulted from the CSC process. The sustainability of the CSC was attributed to good CSC training before SMHILE's close-out, a sense of citizenship and responsibility, the adaptability of the process and witnessing positive benefits from the CSC process. In addition, there is evidence of the following: 1) adaptability of the CSC process, 2) community empowerment, accountability and responsiveness of service providers, expanded spaces for dialogue between service providers and users, and 3) improvements in health service delivery. With these results in mind, CARE is currently conducting a cluster-randomized control evaluation of the CSC's effect on maternal and newborn health service implementation and outcomes in Malawi.